Achilles Tendinopathy: Load It, Do Not Rest It

Pain at the back of the heel that is worst on the first steps of the morning, eases as you warm up, then returns after exercise, is the signature of Achilles tendinopathy. The instinct is to rest it until it stops hurting. That is the one approach least supported by evidence. Tendons adapt to load, and the treatment is a carefully progressed version of the thing that hurt. Here is how it works.

Achilles tendinopathy: the short answer

Loading, not resting, is the treatment. Eccentric heel drops are the most studied protocol, popularised by Alfredson, in which you raise onto both toes and then lower slowly on the affected leg over about three seconds, repeated with the knee straight and bent to target both calf muscles. A scoping review across tendinopathies found eccentric training consistently improved pain and function, with no serious adverse events.

Two useful nuances have emerged since. The exact dose matters less than once thought: a randomised trial found a do-as-tolerated programme worked as well as the classic 180 repetitions a day. And complete rest is unnecessary. In a trial comparing continued tendon-loading activity with six weeks of avoiding it, there was no significant difference in outcomes, provided people followed a pain-monitoring rule. Tendons need around 12 weeks or more to respond structurally, which is why patience is part of the treatment.

What is actually happening in the tendon

Despite the old name tendonitis, this is not primarily an inflammatory problem. The tendon shows disorganised collagen, increased ground substance and new blood vessel growth, changes better described as degeneration and failed healing. That is why anti-inflammatory tablets give limited benefit and why the fix is mechanical rather than pharmaceutical.

Location matters for treatment. Midportion tendinopathy, felt two to six centimetres above the heel bone, responds well to standard heel drops performed off a step with the heel dropping below the level of the toes. Insertional tendinopathy, felt right at the back of the heel bone, often worsens with that full range, and is usually managed with the heel drop limited to floor level, avoiding the stretched position that compresses the tendon against the bone. Getting this distinction right is one of the most common reasons a home programme either works or fails.

The loading programme

Keep it simple and consistent. Progress comes from gradually increasing load over months rather than chasing a hard session.

• Start with heel raises on both legs, lowering slowly over three seconds, if single-leg work is too painful.
• Progress to single-leg eccentric heel drops, rising with both legs and lowering with the affected one.
• Do both variations: knee straight for the gastrocnemius, knee slightly bent for the soleus.
• Three sets of about 15 repetitions, twice daily, or a do-as-tolerated version if that is unmanageable.
• Add load gradually with a backpack once the exercise becomes easy, since the stimulus is the load.
• Limit the range at the floor if your pain is at the heel insertion rather than mid-tendon.
• Allow recovery between heavier sessions, since tendon adaptation happens between sessions rather than during them.

Heavy slow resistance training, using calf raises and seated calf work with substantial weight at a slow tempo, is an alternative with growing support and fewer daily repetitions, which some people stick to better.

How much pain is acceptable

This is where most people go wrong in one direction or the other. The widely used pain-monitoring approach allows discomfort during exercise up to roughly five out of ten, provided it settles by the next morning and does not creep upward week after week. Pain that remains raised 24 hours later means the load exceeded what the tendon could handle that day, and the next session should be lighter rather than skipped.

That framework also allows continued sport in many cases, which matters for people who are told to stop running indefinitely. Reducing volume and intensity while maintaining the loading programme is usually more effective than full rest, because tendons that are unloaded lose capacity and the problem returns as soon as activity resumes. Complete rest has a role only in the short term for a very irritable tendon, and even then movement resumes as soon as it calms.

Timelines and what else helps

Expect months, not weeks. Muscle strength changes take around six to eight weeks, while tendon tissue responds over roughly twelve weeks or more, and returning fully to demanding sport commonly takes four to nine months. Symptoms usually improve well before the tendon has fully recovered, which is exactly when people stop the programme and relapse.

Alongside loading, a few practical measures help. A small heel raise inside the shoe can reduce strain temporarily in insertional cases. Calf flexibility and strength work for the hip and foot address contributing weaknesses. Reviewing training errors matters, since sudden increases in distance, speed or hill work are the usual trigger. Steroid injections into the tendon are generally avoided because of rupture risk. Shockwave therapy and injection treatments are considered when a properly executed loading programme has failed over several months, and surgery is rare.

When to see a physiotherapist or doctor

See a physiotherapist or doctor if heel pain has lasted more than a few weeks, if it limits walking or sport, or if you are unsure whether your pain is midportion or insertional, since the programme differs. Supervised programmes generally produce better results than self-directed ones, mainly because the load progression is managed properly.

Seek urgent assessment for a sudden sharp pain or a snapping sensation at the back of the ankle, especially with difficulty pushing off or walking, which can indicate a ruptured tendon. Also see a doctor for heel pain with swelling, redness and warmth, for pain following a course of fluoroquinolone antibiotics, which are associated with tendon problems, or for pain in both Achilles tendons in a younger adult, which occasionally points to an inflammatory condition. This is general information rather than medical advice, and tendon problems reward early, well-guided loading far more than rest.

Frequently asked questions

Should I rest an Achilles tendon injury?

Not completely. Trials found continued loading with a pain-monitoring rule produced similar results to six weeks of avoiding activity, and unloaded tendons lose capacity.

What are the best exercises for Achilles tendinopathy?

Eccentric heel drops with the knee straight and bent, progressing from double-leg to single-leg and then adding weight. Heavy slow resistance calf work is a good alternative.

How much pain is normal during Achilles exercises?

Up to about five out of ten during the session is generally acceptable, provided it settles by the next morning and does not increase week on week.

How long does Achilles tendinopathy take to heal?

Tendons need around 12 weeks or more to respond to loading, and full return to demanding sport commonly takes four to nine months.

What is the difference between midportion and insertional Achilles pain?

Midportion pain sits two to six centimetres above the heel bone and suits full-range heel drops. Insertional pain sits at the heel bone and usually needs the range limited to floor level.

Read next

• Plantar Fasciitis: Why That First Step Hurts, and What Actually Fixes It

  The other common cause of morning heel pain.

• Best Exercises for Knee Pain Over 50, and What to Avoid

  Loading a painful joint without overdoing it.

• A Simple Daily Mobility Routine for Stiff Bodies

  Supporting calf and ankle mobility alongside loading.

This article is for general informational purposes only and is not medical advice. Always consult a qualified healthcare professional about your individual situation, and never start or stop a medication without your doctor. See our Medical Disclaimer.